Like most health IT projects, CART implementation did not proceed without challenges and some resistance. Strategies learned during CART implementation are summarized in the table. (Table ) Engaged, clinical champions were key facilitators of the entire implementation process; they helped identify a technical champion at their facility to coordinate installation and encouraged overall acceptance of the new clinical application by their peers. At sites where there was an identified clinical champion, implementation was generally much faster.
Key Strategies in CART Implementation
The current health IT literature supports incentivizing adoption,22
although it is important to note that incentives do not necessarily assume a monetary form. In the VA system, clinical champions had a wide array of motivations for adopting CART. Every effort was made to encourage participation in the development process for CART, and to accommodate requests for changes in the application or support mechanisms for future use of site data for research or local quality improvement. In addition, great care was taken to ensure CART would integrate with the workflow of the catheterization lab at the point-of-care, and not significantly increase record-keeping or time, nor require new staff.
Incentives, whatever their form, are necessary to encourage adoption but occasionally are insufficient. In those cases, strong administrative guidance may direct health IT implementation. A VA National Directive was issued at the end of 200529
and mandated the use of CART in all VA catheterization labs. This directive has never been enforced through administrative action, but the presence of such a mandate from management within an integrated healthcare system could be a significant facilitator of implementation for systems like CART.
To combat technical resistance, the VA National Directive mandating CART was occasionally referenced, but more often simply to allay fears that CART might be an ad hoc solution and not part of an approved national quality improvement initiative. Technical champions and staff at each VA placed high value on the ease of CART installation and having a direct communication channel with the CART technical director. Also, CART technical staff maintained up-to-date training and VA security clearance. In a few cases, despite all of this and the existence of a National Directive, it was necessary to provide technical decision-makers with documentation of CART’s national security accreditation before proceeding with installation.
There are several considerations in the interpretation of this paper. CART was implemented in the VA system, which has embraced some form of a computerized record system since the 1980s. VA organizational and financial structures also differ from other health care systems. This may limit the generalizability of CART as a model for health IT implementation outside the VA system. However, as the U.S. health care system moves increasingly towards interoperability and adoption of standards—the hallmarks of ideal electronic health records systems—an application such as CART can be effectively deployed. Moreover, CART may serve as an important model for interoperable, point-of-care clinical applications which document and track quality of care as part of routine clinical workflow. As such, the CART model is extensible to other clinical areas and medical procedures.
To date, CART has achieved its foundational goals. CART has facilitated standardized documentation, such as pre-procedure patient risk and indications, and enhanced communication of the results of catheterization lab procedures within the VA system. CART also supports local site quality assessment reporting, and national reports of catheterization lab volumes, procedure types, and complications to VA leadership.
Successful implementation and adoption have also created new avenues for development. Very soon, CART will allow derivation of quality metrics for national quality oversight by VA leadership, including benchmarking of care among VA’s. Continued technical maintenance and updates of the core application are ongoing, with the CART Clinical Advisory Committee to guide future development requests. The CART Analytic Database is now being developed to link CART to longitudinal care and outcomes from other VA data sources, and to support quality management and health services evaluation. National benchmarking of VA data with the American College of Cardiology National Cardiovascular Data Repository will commence in 2010. Lastly, the VA and FDA have jointly approved a Memorandum of Understanding to support CART as a national network for cardiac catheterization active device surveillance. Through full adoption, CART holds great promise to improve the delivery of care, promote quality improvement, enhance patient safety, facilitate research, and provide useful administrative data assessing catheterization lab volumes, coding, and quality oversight.